Trump Tells G.O.P. to Replace Health Care Law ‘Quickly’
by Maggie Haberman and Margot Sanger-Katz - NYT
President-elect Donald J. Trump pressed Republicans on Tuesday to move forward with the immediate repeal of the Affordable Care Act and to replace it very quickly thereafter, saying, “We have to get to business. Obamacare has been a catastrophic event.”
Mr. Trump’s position undercuts Republican leaders who want a quick vote to repeal President Obama’s signature domestic achievement but who also want to wait as long as two to three years to come up with an alternative. But he was also challenging the resolve of nervous Republicans in Congress who do not want any vote on a repeal until that replacement exists.
Mr. Trump, who seemed unclear about the timing of already scheduled votes in Congress this week, demanded a repeal vote “probably some time next week,” and said “the replace will be very quickly or simultaneously, very shortly thereafter.”
That demand is very likely impossible. Republicans in Congress are nowhere close to agreement on a major health bill that would replace President Obama’s signature domestic achievement. A number of Republicans in the House and Senate have said publicly that they wanted to hold off on voting to eviscerate the health law until a replacement measure could be negotiated.
For now, the Senate is planning to vote Thursday morning on a budget resolution that would set up parliamentary protections for a health care repeal bill that would have to emerge from House and Senate committees by Jan. 27. The House would vote on Friday if that budget measure clears the Senate.
That plan is under pressure from Republicans who want to slow the process as they struggle for an agreement on what would follow repeal.
But Mr. Trump said there was no cause for delay. And he said he would not accept a delay of more than a few weeks before a replacement plan was voted on. “Long to me would be weeks,” he said. “It won’t be repeal and then two years later go in with another plan.” That directly contradicts House Speaker Paul D. Ryan’s plans.
Mr. Ryan, who met privately on Monday with top transition officials, agreed with Mr. Trump on the state of the Affordable Care Act, saying Tuesday that its marketplaces were in a “death spiral.” But he has argued that lawmakers need time to write a bipartisan health bill that would replace it.
In fact, new enrollment numbers from the Obama administration undercut that claim. Despite increasing premiums and a torrent of negative news about the future of the health law, enrollment under the act’s health care plans has continued to grow. There are now 11.5 million people who have chosen the marketplace plans for this year, nearly 300,000 more than at this time last year.
Those numbers do not represent surprising enrollment growth — they are roughly in line with projections put out by the administration a few months ago — but they do suggest that higher prices have not scared away consumers. The proportion of young adults signing up has held steady, a sign that the mix of people buying insurance this year is unlikely to be substantially sicker and more expensive than the people enrolled in plans last year.
“Today’s data show that this market is not merely stable, it is actually on track for growth,” Aviva Aron-Dine, a senior counselor to Sylvia Mathews Burwell, the secretary of Health and Human Services, said in a conference call with reporters. “Today we can officially proclaim these death spiral claims dead.”
The data released Tuesday did not capture all Americans who buy their own insurance plans. While enrollment in health care plans under the act is growing, it will take time to know whether people are continuing to purchase similar plans sold directly by health insurance companies. Those plans have also been subject to large price increases, and the people buying them do not have access to federal subsidies to bring down their premiums and deductibles.
But Mr. Trump showed no sign of willingness to accept the health law any longer.
“It’s a catastrophic event,” he said. “I feel that repeal and replace have to be together, for very simply, I think that the Democrats should want to fix Obamacare. They cannot live with it, and they have to go together.”
Mr. Trump issued a political warning to Democrats who might stand in his way, saying he would campaign against lawmakers, especially in states that he won in November.
“It may not get approved the first time, and it may not get approved the second time, but the Democrats who will try not to approve it” will be at risk, warning that “they have 10 people coming up” for re-election in 2018. That alluded to Democratic senators in states he won.
“I won some of those states by numbers that nobody has seen. I will be out there campaigning,” he said.
Some Republicans Try to Head Off a Health Care Calamity
by The Editorial Board - NYT
President-elect Donald Trump and other Republican leaders may be determined to repeal the Affordable Care Act immediately, but a few more sensible members of the party are now trying to slow down this runaway train. They recognize the danger in destroying a program that directly benefits 22 million Americans — and indirectly millions more by controlling costs — without a plan to replace it.
That perhaps obvious insight has yet to penetrate Mr. Trump’s reality distortion field. He said on Tuesday that Congress should vote to repeal the law as early as next week and replace it with new legislation “very shortly thereafter.” His statements once again demonstrated cluelessness or indifference to how laws are made, especially in a field as complicated as health care. Most experts think that it could well take years for lawmakers to replace a law that requires insurers to sell affordable policies to people with pre-existing medical conditions, provides subsidies to help people buy insurance and encourages doctors and hospitals to reduce unnecessary and expensive medical procedures.
The House speaker, Paul Ryan, claimed on Tuesday that Republicans would try to repeal and replace the law “concurrently.” He offered few details, but his statement suggests Congress won’t repeal the A.C.A. for several months at least. On Monday, five Republican senators — Bill Cassidy of Louisiana, Susan Collins of Maine, Bob Corker of Tennessee, Lisa Murkowski of Alaska and Rob Portman of Ohio — faced up to that reality. They proposed slowing down a budgetary process designed by congressional leaders to effectively kill the most important parts of Obamacare by defunding them.
Two Republican governors, John Kasich of Ohio and Rick Snyder of Michigan, have said that Congress ought to preserve parts of the law, like its expansion of Medicaid, which has improved care for the poor and reduced the heavy burden of charity care at hospitals. About 665,000 people in Ohio and 614,000 in Michigan gained coverage under Medicaid expansion as of December 2015, according to the Kaiser Family Foundation.
The fact is, Obamacare is working, and it is reaching more Americans. As of Dec. 24, about 11.5 million people had signed up for health insurance for 2017 on federal and state health exchanges, 300,000 more than a year earlier. And the law made it possible for 10.7 million people to sign up for Medicaid who did not previously qualify.
Voting for repeal without a decent alternative would be inhumane. It could also be politically disastrous. About 47 percent of Americans don’t want Congress to scrap the law and 28 percent say lawmakers should come up with a replacement first, according to Kaiser.
Repeal’s fiscal consequences also pose a significant problem for Republican deficit hawks like Senator Rand Paul of Kentucky. The budget resolution that is the vehicle for repeal would add more than $2 trillion to the federal debt in the next 10 years, according to the Office of Management and Budget. That’s partly because the law has reduced the deficit by bringing in more revenue than it spends.
If Mr. Trump, his aides and other party leaders have ideas for preserving health coverage, improving medical care and reducing costs, they ought to present them to the public before they start dismantling Obamacare. The truth is, they have nothing more to offer than campaign slogans.
https://www.nytimes.com/2017/01/11/opinion/some-republicans-try-to-head-off-a-health-care-calamity.html?action=click&pgtype=Homepage&clickSource=story-heading&module=opinion-c-col-left-region®ion=opinion-c-col-left-region&WT.nav=opinion-c-col-left-region&_r=0
Senate Takes Major Step Toward Repealing Health Care Law
by Thomas Kaplan and Robert Pear - NYT
WASHINGTON — Senate Republicans took their first major step toward repealing the Affordable Care Act on Thursday, approving a budget blueprint that would allow them to gut the health care law without the threat of a Democratic filibuster.
The vote was 51 to 48. During the roll call, Democrats staged a highly unusual protest on the Senate floor to express their dismay and anger at the prospect that millions of Americans could lose health insurance coverage.
One by one, Democrats rose to voice their objections. Senator Maria Cantwell of Washington said that Republicans were “stealing health care from Americans.” Senator Ron Wyden of Oregon said he was voting no “because health care should not just be for the healthy and wealthy.”
The presiding officer, Senator Cory Gardner, Republican of Colorado, repeatedly banged his gavel and said the Democrats were out of order because “debate is not allowed during a vote.”
The final vote, which ended just before 1:30 a.m., followed a marathon session in which senators took back-to-back roll call votes on numerous amendments, an arduous exercise known as a vote-a-rama.
The approval of the budget blueprint, coming even before President-elect Donald J. Trump is inaugurated, shows the speed with which Republican leaders are moving to fulfill their promise to repeal President Obama’s signature domestic policy achievement — a goal they believe can now be accomplished after Mr. Trump’s election.
The action by the Senate is essentially procedural, setting the stage for a special kind of legislation called a reconciliation bill. Such a bill can be used to repeal significant parts of the health law and, critically, is immune from being filibustered. Congress appears to be at least weeks away from voting on legislation repealing the law.
Republicans say the 2016 elections gave them a mandate to roll back the health care law. “The Obamacare bridge is collapsing, and we’re sending in a rescue team,” said Senator Michael B. Enzi, Republican of Wyoming and the chairman of the Senate Budget Committee. “Then we’ll build new bridges to better health care, and finally, when these new bridges are finished, we’ll close the old bridge.”
Republican leaders say they will work closely with Mr. Trump developing legislation to repeal and replace the health care law, but it is unclear exactly how his team will participate in that effort.
On Wednesday, Mr. Trump said he would offer his own plan to repeal and replace the law “essentially simultaneously.” He said he would put forth the plan as soon as his nominee for secretary of health and human services, Representative Tom Price, Republican of Georgia, is confirmed.
The Affordable Care Act has become ingrained in the American health care system, and unwinding it will be a formidable challenge for Republicans. More than 20 million people have gained coverage under the law, though premiums have risen sharply in many states and some insurers have fled the law’s health exchanges.
The budget blueprint instructs House and Senate committees to come up with repeal legislation by Jan. 27.
Senator Bob Corker, Republican of Tennessee, and four other Republicans had sought to extend that deadline by five weeks, to March 3. But late Wednesday night, Mr. Corker withdrew an amendment that would have changed the date.
“We understand that everyone here understands the importance of doing it right,” he said. He described the Jan. 27 date in the budget blueprint as a placeholder.
Senator Rob Portman of Ohio, another Republican who sought to delay the deadline, said: “This date is not a date that is set in stone. In fact, it is the earliest we could do it. But it could take longer, and we believe that it might.”
The House was planning to take up the budget blueprint once the Senate approved it, though some House Republicans have expressed discomfort with voting on the blueprint this week because of lingering questions over how and when the health care law would be replaced.
A vote on the measure in the House could come on Friday.
In its lengthy series of votes, the Senate rejected amendments proposed by Democrats that were intended to allow imports of prescription drugs from Canada, protect rural hospitals and ensure continued access to coverage for people with pre-existing conditions, among other causes.
In the parlance of Capitol Hill, many of the Democrats’ proposals were “messaging amendments,” intended to put Republicans on record as opposing popular provisions of the Affordable Care Act. The budget blueprint is for the guidance of Congress; it is not presented to the president for a signature or veto and does not become law.
As the Senate plowed through its work on Wednesday, Republicans explained why they were determined to dismantle the health care law, and they tried to assuage concerns about the future of coverage for millions of Americans.
“This is our opportunity to keep our campaign promise,” said Senator Roger Wicker, Republican of Mississippi. “This is our opportunity to help the president-elect and the vice president-elect keep their campaign promises and show to the American people that elections have consequences.”
Senator Johnny Isakson, Republican of Georgia, said that while working to repeal the health care law, “we must also talk about what we replace it with, because repealing it without a replacement is an unacceptable solution.”
Republicans do not have an agreement even among themselves on the content of legislation to replace the Affordable Care Act, the timetable for votes on such legislation or its effective date.
Senator Susan Collins, Republican of Maine, said on Wednesday that she agreed with Mr. Trump that Congress should repeal the health law and adopt a replacement plan at about the same time.
“But I don’t see any possibility of our being able to come up with a comprehensive reform bill that would replace Obamacare by the end of this month,” she said. “I just don’t see that as being feasible.” (Ms. Collins also supported pushing back the deadline to come up with repeal legislation.)
As Republicans pursue repealing the law, Democrats contend that Republicans are trying to rip insurance away from millions of Americans with no idea of what to do next.
The Senate Democratic leader, Chuck Schumer of New York, called the Republicans’ repeal plan “irresponsible and rushed” and urged them to halt their push to unravel the law.
“Don’t put chaos in place of affordable care,” he said.
Seven Questions About Health Reform
by Herald Pollock and Timothy Jost - NYT
On Tuesday, Donald J. Trump said he wanted Congress to repeal the Affordable Care Act right away and replace it with a new plan “very shortly thereafter.” But before they abandon all the work that has gone into the health care law since 2010, President-elect Trump and Republicans in Congress owe Americans a detailed explanation of how they plan to replace it. They should not repeal the law until they have submitted their replacement proposal for analysis by nonpartisan authorities like the Congressional Budget Office and the Tax Policy Center to determine how it will affect health insurance coverage, state and federal finances and individual tax burdens.
Vague promises are not enough when we are considering enormous changes in this country’s $3 trillion medical economy. Here are seven important questions that Congress must answer about its replacement plan before repealing the Affordable Care Act:
1. How many millions of Americans will lose coverage? The A.C.A. expanded Medicaid coverage to around 12 million people in 31 states and the District of Columbia, and provided financial assistance for moderate-income Americans to buy insurance. These measures have reduced the percentage of Americans who are uninsured to the lowest levels in history. Proposals by Tom Price, Mr. Trump’s choice to run Health and Human Services, and by the House speaker, Paul D. Ryan, would repeal the expansion of Medicaid and replace the A.C.A.’s income-based subsidies with less generous tax credits. Another plan from the House Republican Study Committee would offer deductions. We particularly need to know how this would affect low-income Americans, to whom tax deductions are nearly worthless, and who would generally not be able to afford coverage under these plans.
2. Will people over 55 pay higher health premiums for the same coverage? Under the health care law, premiums for older people cannot be more than three times as much as premiums for younger people. But the Ryan plan would let insurers charge older people five times as much. This change, combined with smaller tax credits or deductions that would not compensate for the increased cost, would significantly increase health care costs for many older Americans.
3. Will the new plan let insurers charge women higher premiums than men while offering them less coverage? Before the A.C.A. banned gender-based premiums, insurers in many states charged women more than men of the same age — some as much as 50 percent more. The A.C.A. also required all insurers to cover preventive health services without co-payments; for women, this includes birth control, Pap smears, mammograms and a host of other crucial services. Maternity care is fully covered as well. Republican replacement plans offer no such protection. And many Republicans want to defund Planned Parenthood, too, which would deprive women not just of coverage but also of care.
4. What other services are likely to be cut? Before the A.C.A., about a third of individual insurance market enrollees lacked coverage for the treatment of addiction, and nearly 20 percent lacked mental health coverage. One recent Republican proposal would require coverage only for hospital, physician and emergency care services. Will insurers be allowed to exclude any other services that they choose not to cover?
5. Will the new plan let insurers reinstate annual or lifetime limits on coverage? If so, how would the government ensure that individuals with life-altering illnesses and injuries received care without falling into financial ruin? Before the A.C.A., more than 50 percent of workplace insurance plans had lifetime limits, often in the range of $1 million to $2 million. That sounds like a lot — unless you are a 42-year-old man with leukemia. And “mini-med” policies often imposed annual limits of a few thousand dollars.
6. What will happen to the more than 130 million Americans with pre-existing conditions? Among the most important — and popular — provisions of the A.C.A. are its requirements that insurers cover and not charge higher premiums to people who have pre-existing conditions like cancer.
Some replacement plans propose segregating these people in high-risk pools. Before the A.C.A., two-thirds of states had such pools, which offered health plans with high premiums and deductibles and annual and lifetime caps. The pools never received enough support from the states to respond to the needs of high-cost individuals, and still covered only a tiny fraction of people with pre-existing conditions.
Other plans would protect individuals with pre-existing conditions from discrimination only if they maintained insurance coverage without any breaks. But this is not easy because of job loss and transient hardships. An estimated 44 million Americans experienced a gap in coverage of at least one month in 2013 or 2014.
7. Finally, how much more will those with costly illnesses or injuries have to pay in out-of-pocket costs? Critics of the A.C.A. often argue that the law has made health care unaffordable. But many Americans would pay much more without it. The A.C.A. capped out-of-pocket spending at $7,150 for individuals and $14,300 for families for 2017. Republican proposals appear to offer no protection from high deductibles and other cost-sharing.
This is a short list. One might ask many other important questions about changes to Medicare, Medicaid and insurance bought through employers. Before Congress leaps off the precipice of repeal, Americans have the right to ask, “Where will we land?”
Democrats to force tough votes in Obamacare ‘Vote-a-rama’
by Kelsey Snell and Mike Debones - Washington Post
Senate Democrats prepared Wednesday to make a late-night show of resistance against gutting the Affordable Care Act by forcing Republicans to take politically charged votes against protecting Medicare, Medicaid and other health-care programs.
The mostly symbolic votes come amid growing concerns among congressional Republicans that the party is rushing to dismantle the ACA without a plan to replace it. Democrats planned to force the frenzied vote series called a “vote-a-rama” well into Thursday morning, even as they cannot prevent the GOP from following through on their repeal plans.
Senate Minority Leader Charles E. Schumer (D-N.Y.) said Wednesday that Democrats intend to ensure Republicans are held responsible for any chaos caused by ending President Obama’s landmark law providing roughly 20 million people with coverage in various ways.
“Put this irresponsible and rushed repeal plan aside,” Schumer said on the Senate floor. “Work with us Democrats on a way to improve health care in America, not put chaos in place of affordable care.”
In his news conference on Wednesday, President-elect Donald Trump insisted repeal would not occur without a replacement plan. “Obamacare is the Democrats’ problem. We’re going to take the problem off the shelves for them. We’re doing them a tremendous favor,” Trump said.
Democrats to force tough votes in Obamacare ‘Vote-a-rama’
Senate Democrats prepared Wednesday to make a late-night show of resistance against gutting the Affordable Care Act by forcing Republicans to take politically charged votes against protecting Medicare, Medicaid and other health-care programs.
The mostly symbolic votes come amid growing concerns among congressional Republicans that the party is rushing to dismantle the ACA without a plan to replace it. Democrats planned to force the frenzied vote series called a “vote-a-rama” well into Thursday morning, even as they cannot prevent the GOP from following through on their repeal plans.
Senate Minority Leader Charles E. Schumer (D-N.Y.) said Wednesday that Democrats intend to ensure Republicans are held responsible for any chaos caused by ending President Obama’s landmark law providing roughly 20 million people with coverage in various ways.
“Put this irresponsible and rushed repeal plan aside,” Schumer said on the Senate floor. “Work with us Democrats on a way to improve health care in America, not put chaos in place of affordable care.”
In his news conference on Wednesday, President-elect Donald Trump insisted repeal would not occur without a replacement plan. “Obamacare is the Democrats’ problem. We’re going to take the problem off the shelves for them. We’re doing them a tremendous favor,” Trump said.
NEW YORK, NY - JANUARY 11: President-elect Donald Trump says that Obamacare should be repealed and replaced at the same time (Photo by Jabin Botsford/The Washington Post) (Jabin Botsford/The Washington Post)
Senators are expected to vote Thursday morning on a budget measure — which is likely to pass — setting in motion the framework for the ACA’s repeal. The House is then expected to take up the measure on Friday, though there were signs that disparate groups of House Republicans were concerned about it.
Moderates said they may oppose the measure because they are nervous about starting the repeal without a replacement plan.
Rep. Charlie Dent (R-Pa.), co-chair of the informal caucus of moderate Republicans called the Tuesday Group, said moderate lawmakers have “serious reservations” about starting the process without replacement plans spelled out.
And members of the House Freedom Caucus called for a fuller plan before any votes are taken — including on the preliminary budget measure.
“We just want more specifics,” said Rep. Mark Meadows (R-N.C.), the caucus chairman. “I’m willing to take a vote today if we have the specifics. So it’s not as much slow it down for slowing-it-down purposes as it is, we need to know what we’re going to replace it with.”
On Wednesday night and Thursday morning, Senate Democrats planned to try to embarrass Republican in the all-night vote series by forcing them to take tough votes on protecting mental health services and womens’ access to health care. One such measure would block the Senate from passing any legislation “that would reduce or eliminate access to mental health services.” Another contains similar prohibitions against cutting funding for maternity care.
Democrats plan to track how Republicans vote — information that could be used during upcoming election campaigns, according to Democratic leadership aides who would not speak on the record to divulge internal party strategy.
The voting marathon is expected to end with a final vote instructing the House and Senate committees to begin work on legislation to render useless major portions of Obamacare.
The internal GOP divisions highlight the difficulty Republicans face in making good on one of their central campaign promises a little more than a week before they assume complete control of Washington.
Once the Senate passes the budget measure, it will be sent to the House, where it will not be subject to lengthy debate,
Pressure from both House Republicans and from Trump’s public comments are prodding Republicans to more quickly produce additional details.
House Majority Whip Steve Scalise (R-La.) said Thursday that lawmakers are “in sync” with Trump’s wishes but added, “I think it’s good that we all continue to press each other to work as quickly as we can.”
Trump’s comments Wednesday, as well as those made Tuesday in a New York Times interview, seem to conflate various aspects of the repeal process and set out what many on Capitol Hill see as an overly ambitious timeline for action.
Scalise and Rep. Patrick J. Tiberi (R-Ohio), chairman of the Ways and Means subcommittee on health, said that lawmakers are taking a close look at what elements of a replacement plan can be included in the initial Obamacare repeal bill.
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That legislation is crucial because Republicans plan to pass it using special budget rules allowing the Senate to approve it with only a simple majority vote rather than a 60-vote supermajority. But Senate rules dictate that only measures with a discrete budgetary impact can use those procedures.
So while Republicans could claim that the bill repealing Obamacare also contains a blueprint for its replacement, other parts would need 60 Senate votes — and thus significant Democratic support.
According to multiple GOP sources, Republicans are looking at whether to use upcoming reauthorizations of existing programs, such as the Children’s Health Insurance Program, as vehicles for Obamacare replacement measures. That could give them leverage to secure cooperation from Democrats.
Another wild card is Trump’s pick for Health and Human Services Secretary, Rep. Tom Price (R-Ga.). Trump suggested Wednesday that Price would play a key role in shaping the Obamacare replacement strategy.
United States Department of Health and Human Services
Office of the Assistant Secretary for Planning and Evaluation
December 2016
Report to Congress:
Social Risk Factors and Performance Under Medicare’s Value-Based Purchasing Programs
Background
There is growing recognition that social risk factors – such as income, education, race and ethnicity, employment, community resources, and social support – play a major role in health. Despite ongoing efforts, significant gaps remain in health and in life expectancy based on income, race, ethnicity, and community environment.
At the same time, the health care system is increasingly moving towards higher levels of provider accountability for the quality, outcomes, and costs of care. Value-based or alternative payment models, which tie payment to the quality and efficiency of health care delivered, are in place in nearly all Medicare settings, including in hospitals, outpatient settings, and post-acute facilities.
These two issues are intersecting. If beneficiaries with social risk factors have worse health outcomes because the providers they see provide low-quality care, value-based purchasing could be a powerful tool to drive improvements in care and reduce health disparities. However, if beneficiaries with social risk factors have worse health outcomes because of elements beyond the quality of care provided, such as the social risk factors themselves, value-based payment models could do just the opposite. If providers have limited ability to influence health outcomes for beneficiaries with social risk factors, they may become reluctant to care for beneficiaries with social risk factors, out of fear of incurring penalties due to factors they have limited ability to influence.
This report, mandated by the Improving Medicare Post-Acute Care Transformation Act of 2014 or the IMPACT Act (P.L. 113-185), shares empirical analysis using existing Medicare data to help address these questions and provides considerations for policymakers while additional work using other data sources continues.
Findings
FINDING 1: Beneficiaries with social risk factors had worse outcomes on many quality measures, regardless of the providers they saw, and dual enrollment status was the most powerful predictor of poor outcomes.
FINDING 2: Providers that disproportionately served beneficiaries with social risk factors tended to have worse performance on quality measures, even after accounting for their beneficiary mix. Under all five value-based purchasing programs in which penalties are currently assessed, these providers experienced somewhat higher penalties than did providers serving fewer beneficiaries with social risk factors.
Strategies and Considerations
STRATEGY 1: Measure and Report Quality for Beneficiaries with Social Risk Factors
Consideration 1: Consider enhancing data collection and developing statistical techniques to allow measurement and reporting of performance for beneficiaries with social risk factors on key quality and resource use measures.
Consideration 2: Consider developing and introducing health equity measures or domains into existing payment programs to measure disparities and incent a focus on reducing them.
Consideration 3: Prospectively monitor the financial impact of Medicare payment programs on providers disproportionately serving beneficiaries with social risk factors.
STRATEGY 2: Set High, Fair Quality Standards for All Beneficiaries
Consideration 1: Measures should be examined to determine if adjustment for social risk factors is appropriate; this determination will depend on the measure and its empirical relationship to social risk factors.
Consideration 2: The measure development community should continue to study program measures to determine whether differences in health status might underlie the observed relationships between social risk and performance, and whether better adjustment for health status might improve the ability to differentiate true differences in performance between providers.
STRATEGY 3: Reward and Support Better Outcomes for Beneficiaries with Social Risk Factors
Consideration 1: Consider creating targeted financial incentives within value-based purchasing programs to reward achievement of high quality and good outcomes, or significant improvement, among beneficiaries with social risk factors.
Consideration 2: Consider using existing or new quality improvement programs to provide targeted support and technical assistance to providers that serve beneficiaries with social risk factors.
Consideration 3: Consider developing demonstrations or models focusing on care innovations that may help achieve better outcomes for beneficiaries with social risk factors.
Consideration 4: Consider further research to examine the costs of achieving good outcomes for beneficiaries with social risk factors and to determine whether current payments adequately account for any differences in care needs.
Conclusions
Social factors are powerful determinants of health. In Medicare, beneficiaries with social risk factors have worse outcomes on many quality measures, including measures of processes of care, intermediate outcomes, outcomes, safety, and patient/consumer experience, as well as higher costs and resource use. Beneficiaries with social risk factors may have poorer outcomes due to higher levels of medical risk, worse living environments, greater challenges in adherence and lifestyle, and/or bias or discrimination. Providers serving these beneficiaries may have poorer performance due to fewer resources, more challenging clinical workloads, lower levels of community support, or worse quality.
The scope, reach, and financial risk associated with value-based and alternative payment models continue to widen. There are three key strategies that should be considered as Medicare aims to administer fair, balanced programs that promote quality and value, provide incentives to reduce disparities, and avoid inappropriately penalizing providers that serve beneficiaries with social risk factors. Measuring and reporting quality for beneficiaries with social risk factors, setting high, fair quality standards for all beneficiaries, and the provision of targeted rewards and supports for better outcomes for beneficiaries with social risk factors, may help ensure that all Medicare beneficiaries can achieve the best health outcomes possible.
Next Steps
The findings outlined in this report represent only the beginning of a body of necessary work around fair and accurate quality measurement in the context of Medicare’s increasing use of value-based purchasing programs. The IMPACT Act lays out specific additional requirements for Study B, including the examination of specific social risk factors not currently available in Medicare data such as health literacy, limited English proficiency, and Medicare beneficiary activation (the degree to which beneficiaries have the knowledge, skill, and confidence to manage their health and health care). Based on the findings in this report, future work may also include examining the impact of measuring and accounting for functional status or frailty on the relationship between social risk factors and performance, and identifying care innovations associated with the achievement of good health outcomes for beneficiaries with social risk factors.
Full report (374 pages):
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Comment by Don McCanne
One of the problems with the various pay-for-performance schemes is that social risk factors play a major role in health care outcomes. Dedicated physicians and hospitals who take care of patients with greater social risks tend to be penalized for factors over which they have no direct control. This 374 page ASPE report was generated at the request of Congress to define this problem and consider solutions.
Skim reading this report leads to the conclusion that the approach to evaluating the role of social risk factors in payment systems using value-based purchasing, alternative payments models and other forms of payment innovation results in profound administrative complexity, with all of its waste, and yet it is still not very effective in correcting payment injustices. And this 374 pages is only the bare beginning of a “a body of necessary work around fair and accurate quality measurement in the context of Medicare’s increasing use of value-based purchasing programs.”
We continue to head down the wrong path. Our target should be to establish universality in health care while financing the system equitably with a system that reduces administrative waste. Instead you would think, based on the responses of the policy community and government bureaucrats, that the problem is that we do not have enough administrative oversight, so they propose more and more and more!
Instead we should reduce administrative waste by establishing a single payer national health program and improve value through global budgets, negotiated payment rates, and administered pricing, plus separate budgeting of capital distribution and system capacity. The latter should help to improve care for patients with higher social risk factors, though we do need to improve social programs that would better address the fundamental factors resulting in otherwise amenable social risks.
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